Effect of Oral Branched‐Chain Amino Acid Supplementation on Postoperative Blood Lactate Levels in Patients Undergoing Pancreatoduodenectomy

Background: Elevations in blood lactate levels have been associated with poor postoperative outcome. The aim of the present study was to determine if preoperative supplementation with branched‐chain amino acids (BCAA) decreases postoperative blood lactate levels in patients undergoing pancreatoduodenectomy. Methods: The cases of 223 consecutive patients who underwent pancreatoduodenectomy were retrospectively reviewed. Postoperative blood lactate levels in patients who were treated with BCAA supplementation before pancreatoduodenectomy (December 2011–December 2014) were compared with levels in patients who were not pretreated (January 2008–November 2011). Results: Postoperative lactate levels were significantly lower in patients who received preoperative BCAA supplementation than in patients who did not (2.6 vs 3.1 mmol/L, P = .005), although preoperative blood lactate levels were statistically equivalent between the groups. In the univariate analysis, preoperative BCAA supplementation, preoperative lactate levels, operation time, and postoperative glucose levels were associated with postoperative lactate levels. A multiple regression analysis was performed among the 4 factors, and the preoperative use of BCAA supplementation was independently correlated with postoperative lactate levels (P = .046). Conclusions: Preoperative BCAA supplementation decreased postoperative blood lactate levels. These results suggest that preoperative BCAA supplementation may help patients recover after surgery.     

Usefulness of granular BCAA after hepatectomy for liver cancer complicated with liver cirrhosis

OBJECTIVE: Nutritional disturbances such as ascites and hypoalbuminemia frequently arise after hepatectomy for liver cancer with liver cirrhosis. We examined the possibility of maintaining a favorable state of nutrition by outpatient administration of branched-chain amino acid (BCAA) granules. METHODS: Forty-three patients who had gross liver cirrhosis complicated by liver cancer and underwent surgery up to May 2002 were given BCAA granules (n = 21, BCAA group) or no granules (n = 22, control group). RESULTS: 1) Background details such as age, sex, surgical technique, blood loss, and duration of surgery showed no significant differences. 2) Among objective findings, improvement of ascites and edema tended to occur sooner in the BCAA group, but without a significant difference. 3) Although serum albumin recovered its preoperative value 9 mo after surgery in the control group, only 6 mo was required for recovery in the BCAA group. Total protein showed similar changes, but neither group showed any difference in changes of aspartate aminotransferase, alanine transferase, or platelets. 4) One year postoperatively, the change from the preoperative indocyanine green retention rate at 15 min after intravenous administration tended to be worse in the control group, but not significantly so. 5) In the BCAA group, hyaluronic acid and type IV collagen 7S improved significantly sooner than in the control group. CONCLUSIONS: BCAA supplementation after hepatectomy promotes rapid improvement in protein metabolism and inhibits progression to liver cirrhosis. Administration of BCAA after hepatectomy is considered beneficial to a patient's nutritional state.     

Periexercise coingestion of branched-chain amino acids and carbohydrate in men does not preferentially augment resistance exercise–induced increases in phosphatidylinositol 3 kinase/protein kinase B–mammalian target of rapamycin pathway markers indicative of muscle protein synthesis

The effects of a single bout of resistance exercise (RE) in conjunction with periexercise branched-chain amino acid (BCAA) and carbohydrate (CHO) ingestion on skeletal muscle signaling markers indicative of muscle protein synthesis were determined. It was hypothesized that CHO + BCAA would elicit a more profound effect on these signaling markers compared with CHO. Twenty-seven males were randomly assigned to CHO, CHO + BCAA, or placebo (PLC) groups. Four sets of leg presses and leg extensions were performed at 80% 1 repetition maximum. Supplements were ingested 30 minutes and immediately before and after RE. Venous blood and muscle biopsy samples were obtained immediately before supplement ingestion and 0.5, 2, and 6 hours after RE. Serum insulin and glucose and phosphorylated levels of muscle insulin receptor substrate 1 (IRS-1), protein kinase B, mammalian target of rapamycin, phosphorylated 70S6 kinase, and 4E binding protein 1 were assessed. Data were analyzed by 2-way repeated-measures analysis of variance. Significant group × time interactions were observed for glucose and insulin (P < .05) showing that CHO and CHO + BCAA were significantly greater than PLC. Significant time main effects were observed for IRS-1 (P = .001), protein kinase B (P = .031), mammalian target of rapamycin (P = .003), and phosphorylated 70S6 kinase (P = .001). Carbohydrate and CHO + BCAA supplementation significantly increased IRS-1 compared with PLC (P = .002). However, periexercise coingestion of CHO and BCAA did not augment RE-induced increases in skeletal muscle signaling markers indicative of muscle protein synthesis when compared with CHO.     

Risk Factors for the Development of Catheter‐Related Bloodstream Infections in Patients Receiving Home Parenteral Nutrition

Background: Risk factors for development of catheter‐related bloodstream infections (CRBSI) were studied in 125 adults and 18 children who received home parenteral nutrition (HPN). Methods: Medical records from a national home care pharmacy were reviewed for all patients that had HPN infused at least twice weekly for a minimum of two years from January 1, 2006‐December 31, 2011. Infection and risk factor data were collected during this time period on all patients although those patients who received HPN for a longer period had data collected since initiation of HPN. Results: In adults, 331 central venous catheters (CVCs) were placed. Total catheter years were 1157. Median CVC dwell time was 730 days. In children, there were 53 CVCs placed. Total catheter years were 113.1. Median CVC dwell time was 515 days. There were 147 CRBSIs (0.13/catheter year;0.35/1000 catheter days). In children there were 33 CRBSIs (0.29/catheter year;0.80/1000 days; P < .001 versus adults). In adults, univariate analysis showed use of subcutaneous infusion ports instead of tunneled catheters (P = .001), multiple lumen catheters (P = .001), increased frequency of lipid emulsion infusion (P = .001), obtaining blood from the CVC (P < 0.001), and infusion of non‐PN medications via the CVC (P < .001) were significant risk factors for CRBSI. Increased PN frequency was associated with increased risk of CRBSI (P = .001) in children, but not in adults. Catheter disinfection with povidone‐iodine was more effective than isopropyl alcohol alone. There were insufficient patients to evaluate chlorhexidine‐containing regimens. Conclusion: Numerous risk factors for CRBSI were identified for which simple and current countermeasures already exist.     

Effect of Parenteral Fish Oil Lipid Emulsion in Parenteral Nutrition Supplementation Combined With Enteral Nutrition Support in Patients Undergoing Pancreaticoduodenectomy

Background: The effect of parenteral fish oil lipid emulsion in parenteral nutrition (PN) supplementation combined with enteral nutrition (EN) support on pancreaticoduodenectomy (PD) was investigated with a randomized controlled clinical trial at the Affiliated Drum Tower Hospital. Materials and Methods: Seventy‐six patients who underwent PD in the Department of Hepatobiliary Surgery were randomly divided into 2 groups: the polyunsaturated fatty acid (PUFA) group (n = 38) and control group (n = 38). Patients in the PUFA group received parenteral fish oil lipid emulsion supplementation combined with early EN support for 5 days after PD. Venous blood samples were obtained for assay on the day before surgery and on day 6 after surgery. Results: Compared with the results of the control group, a significant difference was seen in the extent of the decrease in total protein and prealbumin in the PUFA group (P < .05). Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) were significantly decreased on day 6 in the PUFA group (P < .01), and a significant difference was seen in the extent of decrease in ALT, AST, and LDH in the PUFA group (P < .05). The ratio of infectious complications in the PUFA group was significantly decreased, as well as the postoperative hospital stay (P < .05), and there was no hospital mortality in this study. Conclusion: Parenteral fish oil lipid emulsion in PN supplementation combined with EN support can greatly improve the nutrition state and liver function of patients, decrease the incidence of infectious morbidities, and shorten the postoperative hospital stay.     

Influence of Branched-Chain Amino Acid Supplementation on Urinary Protein Metabolite Concentrations after Swimming

Objective: The influence of branched-chain amino acid (BCAA) supplementation on urinary urea nitrogen, hydroxyproline (HP), and 3-methylhistidine (3MH) concentrations after 25 min of breast stroke exercise (65–70% maximum heart rate reserved, 65–70% HRRmax) followed by a 600 m crawl stroke competition was investigated in a double-blind, counter-balanced study.

Methods: Male university students (19–22 years old) majoring in physical education participated in the study. Based on the previous swimming time of a 600 m crawl stroke, the participants were divided into two groups: placebo (n = 9, BMI = 24.2 ± 2.1 kg/m²; 12 g of glucose/day; in capsules) and BCAA (n = 10, BMI = 22.7 ± 1.5 kg/m²; 12 g of BCAAs/day; in capsules: leucine 54%, isoleucine 19%, valine 27%) groups. The participants maintained a regular dietary intake (except the prescribed breakfast on day 15) and exercise activity at a moderate/low intensity (60–70% HRRmax, swimming and rowing, ～1.5 hour/day) during the 15-day study. A prescribed exercise program was performed on day 15. Urinary and blood samples were collected before, during, and after the prescribed exercise for the measurements of the urinary urea nitrogen, HP, and 3MH concentrations in urine, as well as the glucose, lactate, glutamine, alanine, and BCAA concentrations in plasma.

Results: Two weeks of dietary supplementation did not induce any changes in the plasma glucose and total BCAA concentrations of either group, nor in the urinary urea nitrogen, HP, and 3MH concentrations in urine. On day 15, after 25 min of breast stroke exercise and a 600 m crawl stroke competition, plasma glucose concentration decreased significantly (p < 0.05) whereas plasma lactate concentration increased significantly (p < 0.05) in both groups. The exercise program prescribed in the study did not affect urinary urea nitrogen, HP, and 3MH concentrations. Twenty hours after the competition, however, a significant increase in the concentrations of urinary urea nitrogen, HP, and 3MH was found in the placebo group (p < 0.05), but not in the BCAA group.

Conclusions: The results obtained in this study suggest that swimming induced muscle proteolysis was prevented by BCAA supplementation. The mechanism could be attributed to the availability of ammonia provided by the oxidation of supplemented BCAAs during exercise.     

Effects of perioperative synbiotic treatment on infectious complications, intestinal integrity, and fecal flora and organic acids in hepatic surgery with or without cirrhosis

Background: The aim of this study was to assess the effect of preoperative and postoperative synbiotic treatment in hepatectomy patients with or without liver cirrhosis. Methods: Sixty‐one patients with hepatic cancer were assigned randomly to receive either oral synbiotics that consisted of Bifidobacterium, Lactobacillus, and galactooligosaccharides or no synbiotics (control) preoperatively for 14 days and postoperatively for 11 days. Infectious complications, intestinal mucosal integrity as measured by serum diamine oxidase (DAO) activity, and fecal flora and organic acid concentrations were compared between synbiotic treatment (n = 32) and control (n = 29) groups. Results: Fecal flora culture and organic acid concentrations were changed after hepatectomy in both groups. The postsurgery decrease in DAO activity was less profound in the synbiotic‐treated group (P < .01) and was correlated negatively with serum interleukin 6 and C‐reactive protein concentrations (P < .001). Infectious complications occurred in 5 (17.2%) patients in the control group and no patients in the synbiotic‐treated group (P < .05). Conclusion: Perioperative synbiotic treatment attenuated the decrease in intestinal integrity and reduced the rate of infectious complications in patients with or without liver cirrhosis who underwent hepatic surgery.     

Improved Glucose Profile in Patients With Type 2 Diabetes With a New,High‐Protein,Diabetes‐Specific Tube Feed During 4 Hours of Continuous Feeding

Background: Hyperglycemia frequently occurs in hospitalized patients receiving nutrition support. In this study, the effects of a new diabetes‐specific formula (DSF) on glucose profile during 4 hours of continuous feeding and 4 hours after stopping feeding were compared with a standard formula (SF). Materials and Methods: In this randomized, controlled, double‐blind, crossover study, ambulant, nonhospitalized patients with type 2 diabetes received the DSF or an isocaloric, fiber‐containing SF via a nasogastric tube. After overnight fasting, the formula was continuously administered to the patients during 4 hours. Plasma glucose and insulin concentrations were determined during the 4‐hour period and in the subsequent 4 hours during which no formula was provided. Results: During the 4‐hour feeding period, DSF compared with SF resulted in a lower mean delta glucose concentration in the 3‐ to 4‐hour period (0.3 ± 1.0 and 2.4 ± 1.5 mmol/L; P < .001). Also, the (delta) peak concentrations, (delta) mean concentrations, and incremental area under the curve (iAUC) for glucose and insulin were significantly lower during DSF compared with SF feeding (all comparisons: P < .001). Furthermore, fewer patients experienced hyperglycemia (>10 mmol/L) on DSF compared with SF (2 vs 11, P = .003, respectively). No differences in number of patients with hypoglycemia (<3.9 mmol/L) were observed. No significant differences in tolerance were observed. Conclusion: Administration of a new, high‐protein DSF during 4 hours of continuous feeding resulted in lower glucose and insulin levels compared with a fiber‐containing SF in ambulant, nonhospitalized patients with type 2 diabetes. These data suggest that a DSF may contribute to lower glucose levels in these patients.     

中国成年人血糖水平现状及其与体质指数和腰围的关系

目的 描述我国成年人血糖水平现状,探讨BMI、腰围与血糖水平的关系。方法 数据源于2018年中国慢性病及危险因素监测,采用多阶段分层整群随机抽样方法在全国31个省（自治区、直辖市）的298个监测区（县）选取≥18岁常住居民,以面对面问卷调查、身体测量和实验室检查方法收集人口学基本信息、慢性病危险因素信息、BMI、腰围和血糖水平等。对数据进行复杂加权后,分组描述不同特征人群的血糖水平,并利用多重线性回归分析不同特征人群的BMI及腰围与FPG及糖化血红蛋白的关系。结果 共纳入177 816名研究对象,我国成年人FPG和糖化血红蛋白分别为（5.73±1.46）mmol/L、（5.37±0.83）%,其中,均以≥60岁年龄组最高,男性均高于女性（P<0.001）,城市的平均糖化血红蛋白略高于农村（P<0.001）;平均FPG和平均糖化血红蛋白均随BMI和腰围的增长而增高（P<0.001）。多重线性回归校正混杂因素后,BMI每增加1 kg/m²,未诊断为糖尿病、新诊断为糖尿病和自报已诊断为糖尿病的FPG分别增加0.019 mmol/L（P<0.001）、0.021 mmol/L（P=0.163）和0.028 mmol/L（P=0.088）;糖化血红蛋白分别增加0.015%、0.050%和0.033%（均P<0.001）。腰围每增加1 cm,亚人群的FPG分别增加0.008 mmol/L（P<0.001）、0.014 mmol/L（P=0.004）、0.023 mmol/L（P<0.001）;糖化血红蛋白分别增加0.006%、0.019%、0.019%（均P<0.001）。腰围的标准化β值均高于BMI。结论 未被诊断为糖尿病且BMI或腰围高于正常值的成年人是重点防控人群。腰围预测血糖水平的能力高于BMI,应加大举措提高腰围知晓率,有助于实现各人群维持血糖正常。     

Effects of Preoperative Enteral Nutrition on Postoperative Recent Nutritional Status in Patients with Siewert II and III Adenocarcinoma of Esophagogastric Junction after Neoadjuvant Chemoradiotherapy

Objective: To study the effects of preoperative enteral nutrition (EN) on postoperative recent nutritional status (PRNS) in patients with Siewert II and III adenocarcinomas of esophagogastric junction (AEG) after neoadjuvant chemoradiotherapy (NCRT).

Methods: A total of 66 patients with resectable AEG (Siewert II and III) were randomly divided into two groups. The trial group accepted oral nutrition supplementation (ONS) for 7 days before surgery while the control not.

Results: Nutrition indexes were higher in trial group after surgery whereas the opposite was true for the diamine oxidase (DAO) and d-lactate (P?<?0.05). The rate of malnutrition and nutritional risk became lower in trial group on the 8th day after surgery (P?<?0.05). Injury levels of intestinal mucosa were more severe among control group. The recent prognosis was better in trial group. For patients with or without nutritional risks at admission, the PRNS and recent prognosis were improved by preoperative EN. Logistic regression analysis suggested that preoperative EN could be an independent protective factor of PRNS.

Conclusions: Preoperative EN may improve the PRNS and recent prognosis of patients with Siewert II and III AEG after NCRT.     

Impact of Postoperative Weight Loss on Survival After Resection for Pancreatic Cancer

Background: The aim of this study was to assess the effects of postoperative body weight loss on long‐term survival after resection for pancreatic cancer. Methods: A total of 93 patients with primary pancreatic cancer underwent pancreatic resection between April 2005 and December 2011. Patient characteristics, preoperative body mass index, and changes in postoperative body weight were evaluated retrospectively and correlated with long‐term survival. Results: There was no significant association between survival and preoperative body mass index. Body weight fell by 8.4% at 2 months after surgery and by 9.0% at 4 months after surgery. Severe postoperative body weight losses, both at 2 months (P = .033) and 4 months (P = .014) after surgery, were significantly associated with poor prognosis, especially among patients with stage IA–IIA pancreatic cancer (n = 43) (P = .005 at 2 months and P < .001 at 4 months). Additionally, severe body weight loss tended to be associated with shorter survival among patients with stage IIB–III pancreatic cancer (n = 50), although the difference was not significant. Multivariate analysis revealed that postoperative body weight loss was an independent prognostic factor. Conclusions: The results of this study demonstrated that pancreatic cancer patients with severe postoperative body weight loss have poorer postoperative outcomes.     

Laparoscopic Surgery Improves Blood Glucose Homeostasis and Insulin Resistance Following Distal Gastrectomy for Cancer

Background: Prevention of blood glucose elevation and insulin resistance could be more pronounced in patients undergoing laparoscopic rather than open gastrectomy. Methods: Fifty‐seven patients underwent distal gastrectomy by either laparoscopy (n = 36) or an open approach (n = 21). Blood glucose, serum insulin, and the daily insulin secretion rate (urinary C‐peptide) were measured. Insulin resistance was evaluated using an adapted homeostasis model assessment of insulin resistance (HOMA‐R). Results: Blood glucose levels were lower in the laparoscopy group than in the open group on the operative day and on postoperative days (POD) 1 and 3 (P< .001, P = .001, and P = .024, respectively). Serum insulin levels were lower in the laparoscopy group than in the open group on POD 1 and 3 (P = .045 and P = .027, respectively). HOMA‐R was lower in the laparoscopy group than in the open group on POD 1 and 3 (P = .024 and P = .009, respectively). Daily insulin secretion rates were lower in the laparoscopy group than in the open group on POD 1 (P = .023). Conclusions: Laparoscopic surgery prevents blood glucose elevation and improves insulin resistance compared with open surgery.     

Multitargeted Feeding Strategies Improve Nutrition Outcome and Are Associated With Reduced Pneumonia in a Level 1 Trauma Intensive Care Unit

Background: Factors impeding delivery of adequate enteral nutrition (EN) to trauma patients include delayed EN initiation, frequent surgeries and procedures, and postoperative ileus. We employed 3 feeding strategies to optimize EN delivery: (1) early EN initiation, (2) preoperative no nil per os feeding protocol, and (3) a catch‐up feeding protocol. This study compared nutrition adequacy and clinical outcomes before and after implementation of these feeding strategies. Methods: All trauma patients aged ≥18 years requiring mechanical ventilation for ≥7 days and receiving EN were included. Patients who sustained nonsurvivable injuries, received parenteral nutrition, or were readmitted to the intensive care unit (ICU) were excluded. EN data were collected until patients received an oral diet or were discharged from the ICU. The improvement was quantified by comparing nutrition adequacy and outcomes between April 2014–May 2015 (intervention) and May 2012–June 2013 (baseline). Results: The intervention group (n = 118) received significantly more calories (94% vs 75%, P < .001) and protein (104% vs 74%, P < .001) than the baseline group (n = 121). The percentage of patients receiving EN within 24 and 48 hours of ICU admission increased from 41% to 70% and from 79% to 96% respectively after intervention (P < .001). Although there were fewer 28‐ay ventilator‐free days in the intervention group than in the baseline group (12 vs 16 days, P = .03), receipt of the intervention was associated with a significant reduction in pneumonia (odds ratio, 0.53; 95% confidence interval, 0.31–0.89; P = .017) after adjusting sex and Injury Severity Score. Conclusions: Implementation of multitargeted feeding strategies resulted in a significant increase in nutrition adequacy and a significant reduction in pneumonia.     

Organophosphate Pesticide Exposure in School-Aged Children Living in Rice and Aquacultural Farming Regions of Thailand

Organophosphate pesticides (OPs) are widely used in agricultural sectors in Thailand. Previous studies have documented that children residing in agricultural areas have higher exposure to OPs than children living in other residential areas. The objective of this study was to quantify urinary biomarkers of OP exposure and determine the environmental conditions and activities that predict their levels among children living in Central Thailand farming regions. In October 2011, 53 6–8-year-old participants were recruited from Pathum Thani Province, Thailand. Twenty-four lived in rice farming communities at Khlong Luang District where OPs are the pesticides used frequently. Twenty-nine participants, living in aquacultural farming communities at Lum Luk Ka District where OPs are not used, were recruited to serve as controls for pathways of exposure (e.g., residential, dietary) other than occupational/paraoccupational exposures encountered in rice farming. Household environments and participants’ activities were assessed using a parental structured interview. Urine samples (first morning voids) were collected from participants for OP urinary metabolite (i.e., dialkylphosphates [DAPs] and 3,5,6-trichloro-2-pyridinol [TCPy]) measurements. The levels of most urinary OP metabolites were significantly higher in participants who lived in a rice farming community than those who lived in an aquacultural farming community (P < .05). The results from linear regression analysis revealed that the frequency of OP application on rice farms (∑DAP: P = .001; TCPy: P = .001) and living in a rice farming community (∑DAP: P = .009; TCPy: P < .001) were significant predictors of urinary DAP metabolite levels in participants. Increasing TCPy levels were significantly related to proximity to rice farm (P = .03), being with parent while working on a farm (P = .02), playing on a farm (P = .03), and the presence of observable dirt accumulated on the child’s body (P = .02). In conclusion, OP metabolite levels among children who live in rice farming communities were strongly influenced by farming activity, household environments, and child behaviors, suggesting that these are the primary pathways in which children living in these agricultural communities in Thailand were exposed to OPs.     

Nutrition Management of Home Parenteral Nutrition Among Patients With Enterocutaneous Fistula in the Sustain Registry

Background: Home parenteral nutrition (HPN) is a vital therapy for patients who have the diagnosis of enterocutaneous fistula (ECF), yet little is known about how these patients are managed. This research compares nutrition management of adults with ECF as the indication for HPN therapy to those with other indications. Methods: This is an analysis of data from adult HPN patients in the Sustain registry enrolled between August 2011 and February 2014 who have the diagnosis of ECF or other indication for HPN who served as the control group. Differences between the ECF and control group were assessed by t test, analysis of variance, or χ² as appropriate. Results: There were 141 HPN patients with ECF and 632 control patients. Patients with ECF were older (55 vs 50 years, P < .001), more frequently had a goal for future surgery (30% vs 15%, P = .010), had greater prevalence of overweight/obesity (33% vs 20%, P = .04), and had a lower serum albumin (2.98 ± 0.65 g/dL vs 3.16 ± 0.66 g/dL, P = .006) than controls. The diet order was more frequently nil per os (NPO) in patients with ECF (48% vs 22%, P < .001), and amino acid content of HPN was greater (111.90 ± 29.11 vs 102.06 ± 27.84, P < .001) than in controls. There were no differences in patterns of weight change by ECF or control groups, although underweight patients gained, normal‐weight patients maintained, and overweight/obese patients lost weight and serum albumin increased similarly. Conclusions: The HPN management of patients with ECF is similar to other HPN patients other than greater provision of protein, more frequent NPO status, and a goal for future surgery.     

Anemia in Cutaneous Malignant Melanoma: Low Blood Hemoglobin Level is Associated with Nodal Involvement,Metastatic Disease,and Worse Survival

Anemia is common in cancer patients and also affects survival. However, its clinical role and prognostic significance remains unknown in cutaneous melanoma patients (CMPs). The aim of this study was to determine the clinical significance of blood hemoglobin levels in CMPs. Of 446 CMPs were enrolled into this study and were investigated retrospectively. The median value of hemoglobin levels was 13.4 g/dL (7.9–17.4 g/dL). The female patients (P < 0.001) and those with nodular histology (P = 0.040), elevated erythrocyte sedimentation rate (P < 0.001), higher serum lactate dehydrogenase (P < 0.001), lymph node involvement (P = 0.018), and metastatic disease (P < 0.001) had more likely low hemoglobin concentrations compared with other CMPs. However, serum hemoglobin levels were not significantly associated with age, anatomic localization, and various pathological features including Breslow depth, mitotic rate, and ulceration. We found that hemoglobin levels were significantly associated with outcome; the patients with low hemoglobin concentrations had worse survival than other CMPs (P < 0.001). On multivariate analyses, however, hemoglobin level lost its significance, thus, it was not found independently associated with the outcome. In conclusion, low blood hemoglobin concentration is associated with nodal involvement and metastatic disease. Although anemia in diagnosis was not an independent prognostic factor for survival in CMPs, it was associated with poor prognostic factors.     

Glutamine Restores Tight Junction Protein Claudin‐1 Expression in Colonic Mucosa of Patients With Diarrhea‐Predominant Irritable Bowel Syndrome

Background:Recent studies showed that patients with diarrhea‐predominant irritable bowel syndrome (IBS‐D) had an increased intestinal permeability as well as a decreased expression of tight junctions. Glutamine, the major substrate of rapidly dividing cells, is able to modulate intestinal permeability and tight junction expression in other diseases. We aimed to evaluate, ex vivo, glutamine effects on tight junction proteins, claudin‐1 and occludin, in the colonic mucosa of patients with IBS‐D. Materials and Methods: Twelve patients with IBS‐D, diagnosed with the Rome III criteria, were included (8 women/4 men, aged 40.7 ± 6.9 years). Colonic biopsy specimens were collected and immediately incubated for 18 hours in culture media with increasing concentrations of glutamine from 0.6–10 mmol/L. Claudin‐1 and occludin expression was then measured by immunoblot, and concentrations of cytokines were assessed by multiplex technology. Claudin‐1 expression was affected by glutamine (P < .05, analysis of variance). In particularly, 10 mmol/L glutamine increased claudin‐1 expression compared with 0.6 mmol/L glutamine (0.47 ± 0.04 vs 0.33 ± 0.03, P < .05). In contrast, occludin expression was not significantly modified by glutamine. Interestingly, glutamine effect was negatively correlated to claudin‐1 (Pearson r = ‐0.83, P < .001) or occludin basal expression (Pearson r = ‐0.84, P < .001), suggesting that glutamine had more marked effects when tight junction protein expression was altered. Cytokine concentrations in culture media were not modified by glutamine treatment. Conclusion: Glutamine increased claudin‐1 expression in the colonic mucosa of patients with IBS‐D. In addition, glutamine effect seems to be dependent on basal expression of tight junction proteins.     

Predictors of Insulin Requirements Among Hospitalized Adults Receiving Parenteral Nutrition

Objective: The objective of this quality improvement project was to determine factors predictive of parenteral nutrition (PN) insulin therapy. Methods: Patients receiving PN at a tertiary care academic medical center between January 1, 2009, and December 1, 2012, 18 years or older were included. Variables collected included demographics, medical information, and PN‐specific data. χ² and Student t tests were used to determine differences between patients who did and did not require PN insulin. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to determine associations between characteristics. Stepwise forward logistic regression was used determine the best predictors of PN insulin. Results: A total of 1388 patients were started on PN. After adjusting for potential confounders, strong associations existed between PN insulin requirements and diabetes mellitus (DM) diagnosis (OR, 8.90; 95% CI, 4.98–15.90, P < .001), overweight/obese status (body mass index ≥25.0 kg/m²) (OR, 2.12; 95% CI, 1.04–4.30, P = .04), intensive care unit (ICU) admission (OR, 1.79; 95% CI, 1.03–3.11, P = .04), blood glucose (BG) on day of PN start >120 mg/dL (OR, 2.32; 95% CI, 1.32–4.05, P = .003), mean BG >180 mg/dL while receiving PN (OR, 6.10; 95% CI, 2.18–17.04, P = .001), and hemoglobin A1c (A1c) ≥5.7% (OR, 3.18; 95% CI, 1.84–5.50, P < .001). Among variables available at PN initiation, DM diagnosis (P < .001), A1c ≥5.7% (P < .001), BG >120 mg/dL on PN start day (P < .001), and ICU admission (P < .001) predicted the need for PN insulin.